Method and Field Work Conditions
The following account is based on twenty-two months of field work in Nepal, between January 1989 and March 1992. I am trained as a nurse and was one of the expatriates working with a British non governmental organisation (the Britain Nepal Medical Trust; BNMT) which ran a health project in Eastern Nepal. The backbone of this was a TB control programme covering eight hill districts. My position differed from the other expatriates in that I was seconded by another organisation, a Norwegian agency which was a funder to the British project. My roles were thus manifold, connected as I was to two different organisations, employed in some way by both, while at the same time trying to do anthropological research, and get integrated in the local community. The situation should give ample scope for role confusion and conflicts, but at the same time it offers opportunities for shifting positions and perspectives.
Collecting information about preconditions for effective TB control as well as the general situation of TB patients in the area, was part of my job assignment. In the beginning this took all of my time. Later on I also got involved in the upstart of a project meant to promote a dialogue between traditional healers and health post workers, motivated by the findings from the initial research.
I moved about a great deal, especially in the beginning of my stay. Before the completion of my term I had visited all the districts BNMT worked in. I met most of the staff of the TB clinics which were situated in each of the district centres. I met and talked with TB patients in the clinics, and visited many of them in their homes. During the second year I settled down in one of the hill districts, Bhojpur. I still moved about, but mainly within the district. With a more stable base, I had a chance to get to know people who suffered from TB, not only through the clinic encounters, but as neighbours and friends. I also got a better opportunity to learn about beliefs and perceptions pertaining to the disease, not only from those suffering from it, but from the wider community they belonged to.
Language studies started well in advance of going out to Nepal, and continued throughout my stay in the country. I was very lucky to find local language assistants with remarkable communication skills. Their contribution, as coworkers and friends, was tremendous. Most of the data from interviews are derived from conversations I had with people together with a language assistant, in which I could take an increasingly active part. During the course of my stay, I could more easily derive information from discussions with people when I was without language assistants.
The family who became my hosts lived by the side of the main road leading to the district centre, half an hour's walk away from the bazaar. The house in which I stayed had recently been constructed. I stayed there with another tenant, while the family lived on in the old house. This arrangement gave me a chance to withdraw which I came to appreciate, as my social life could be rather intense at times. I shared meals with the family. The number of other people eating there could vary considerably. Living at the side of the road, with the wall to the road usually being open, many people would drop in on their way to and from the district centre. Some stayed overnight, spontaneously or planned, especially at the time of the weekly market. The skill of my hostess as a cook and a liquer-producer could partly explain why so many people were attracted to the house.
My hosts belonged to the Rai community, people who claimed to be aborigines of the area. They were rooted in a local way of life, but had links to foreign countries and different approaches to life, mainly through their children. The husband and wife came from two different Rai subgroups, Bantaw a and Chamlinge Rai. Even though they did not understand each other's native languages and talked to each other in Nepali, their marriage was in accordance with traditional rules. The head of the family was a pensioned Gurkha soldier. The couple had four children. The youngest daughter still lived at home, attending the local school. The other daughter, who was born in Hong Kong, was married to a Gurkha and stayed in Singapore at the time. The eldest son served in the army in India, and the youngest studied in Kathmandu. Two other children of poorer relatives stayed with them while I was there: a boy and a girl, who helped out with the house work. The boy also went to school. Worried about the workload and need for help in the house, the mother was eager for the eldest son to get married. While I was there, he was called home to get introduced to a selection of women, but he blankly refused any matrimonial arrangement. The experience and connections abroad in the midst of a "traditional way of life," struck me and surprised me at first, but I learnt that it was not unique to this family at all.
My daily contact with the family gave me a home, and introduced me to worries and joys in a local family's life. At the same time, staying separately gave me more freedom to receive others as I wanted. Current or ex-TB patients, like untouchables, are to a large extent restricted from entering other people's houses in Bhojpur. That I lived alone, was puzzling to my neighbours, though. People who heard about it would often come to check if this was really so. "I have come to have a look!" they would declare, scrutinizing the rooms.
Through informal contact, structured and semi-structured interviews with patients during and after treatment at TB clinics, observation of sickness episodes in my day-to-day contact with local people, and being present at numerous encounters between patients and health workers in clinics, hospitals and health posts, I became increasingly alert to the vital role traditional methods and beliefs in healing played for local people in Bhojpur, whether for TB, or sickness in general. I came to suspect that a lack of recognition of the importance of these traditions could have consequences for the professional health workers chances of obtaining patient compliance in their combat against the fatal disease which TB truly is.
This concern brought me into contact with dhami s and jhankri, the main categories of traditional healers in Nepal. During my second year there, a trial project was started to promote a dialogue between this group and health post workers. One main purpose of this book is to show the background for this initiative, and the problems and complications connected with such a collaboration project.
Through the process of setting up and carrying out this pilot project, I became convinced of the importance of a dialogue, but I am not very optimistic about the chances of having such a co- operation project introduced on a large scale. I will try to show the reasons for my sceptisism regarding this.
There is an obvious tension in the effort to combine employment at a health care project and anthropological research like I did during the field work. It is only natural to suspect that the fact that I was associated with a biomedical health project, was a barrier to people opening up to me about their own beliefs and traditions regarding health. I did find that there was a barrier, but to me it seemed that it was as much linked to my origin as to my working place. With my Western and urban background, I was expected to regard their traditions as superstitious oddities in any case.
On my first eager enquires about traditional healers in the area, the answers I got were reluctant and evasive. Most people wanted to deny their own adherence to traditional beliefs: "It is only the old and ignorant people who believe in this." Later on during my stay in the locality, I witnessed situations where the same people who had answered in this way, showed considerable reliance on traditional healers. I came to understand their initial responses as impression management rooted in tensions between village and city, and ideas about "development" and "modern life," which have also been described by Stacy Pigg (1990).
When my position as a family friend and neighbour became more established, situations that brought up the role and function of dhamis and jhankri arose in my day-to-day contact with the people with whom lived. With time patients as well as healers not only accepted, but encouraged, my presence at healing sessions. The barrier that my links with a formal health project had implied, was thus not insurmountable.
I start this account with a case which made a great impression on me during the beginning of my stay in Nepal. The case seemed to reveal a communication gap between the health workers and the family of a patient in one of the TB clinics, which worried and upset me. From a Western, biomedical point of view the behaviour of the patient's relative did not make much sense and the consequences in this case were drastic. The search for an explanation, for some key to information which could illuminate the background for the choices that were made, became an urgent concern to me.
This is the background for this book, which will refer mainly to tuberculosis patients. The disease is very prevalent in Nepal and presents its own challenges to health workers.
Through this discussion we will come across one person who is not visible in the opening case as it is told below, the Nepali traditional healer, the dhami. I will try to show what a crucial role he plays for Nepali sick people, and will argue that neglecting his importance has consequences, not only for the possibility of obtaining patient compliance in the provision of humane treatment, but also for the chances of a successful therapeutic outcome.
I see the traditional healer in Nepal as somebody whose gifts are often not recognized. I will look at the interaction between the biomedical health workers and the traditional healers, and shall show a tension between these groups, but shall also argue that there is a mutual influence between the two. While the distance between their disease epistemiologies and therapeutic methods might appear to be great, there are similarities to be found in the techniques at work, and the distance between them is to a large extent constructed and maintained for reasons beyond the medical arena. I will discuss conflicts between them and try to assess the possibility for collaboration.
What follows is an anthropological study, the author of which is also a nurse. As a nurse, I have been trained in biomedicine. This can sometimes feel like a limiting conditioning that it is challenging to try to overcome. At other times it can seem to provide further instruments for probing into some of the mechanisms behind events, all the more because one group of actors in the drama I have been attending, are trained within the same tradition. Included in the motivation for undertaking the project of writing down this account, is a conviction about the need for chemotherapeutic treatment for TB patients. The book is written in an active search for ways which will include more sick people in therapy. As such the book could be accused of having a biomedical bias. Denying a belief in chemotherapeutic treatment would be false pretense.
Medical anthropology's relationship to clinical practice is a much debated issue within the discipline. Whereas one branch (one of the main advocates of which is Arthur Kleinman) wants to stay in close dialogue with medical practitioners and make their findings available and relevant to them, they are criticized by others (among them Nancy Scheper-Hughes) who maintain that the task of medical anthropology is to criticize the biomedical system, not facilitate its use (and hegemony). Lynn Morgan (1990) has soberly suggested that much of this controversy might be rooted in a competition for limited job opportunities.
The position I take is critical of the way the established biomedical system functions. I see the problem as to some extent inherent in biomedical theory but more so in the way the theory is put into practice. One of the obstacles to an appropriate service is a refusal among many practitioners to admit to a limited role for biomedicine in matters regarding sickness and health, and a pretense at being able to cure everything. I will maintain, however, that biomedical theory contains a lot of insights that go against much of current biomedical practice. Moreover, in the process of writing this book I have found myself in a continuous dialogue with several biomedical practitioners who have shown a great willingness to listen to and to acknowledge different ways of thinking and be critical of their own discipline. Though they can hardly be taken to be "representative" for their profession, these physicians do show that an alternative approach is possible. With this experience, it is difficult for me to join a demand for a medical anthropology which shall only and solely criticise biomedicine, careful not to produce anything which can be used by the practitioners of the discipline.
This question is linked to the wider issue of applied anthropology, which is a controversial issue in itself. My stand is that we should not let "scientific puritanism" prevent us from making our work available for practical purposes. This certainly implies difficult dilemmas connected to the risk of "selling ourselves" and letting financial sources influence the outcome of the research. In my view these are dilemmas we have to live with. Meeting these questions with a sharpened consciousness is part of what it involves to live in the world.
Another issue is our approach to other medical traditions. Should they, too, be solely criticised (as advocates of "critical medical anthropology" have maintained, e.g. Scheper-Hughes 1990)? Or should they be solely praised? If the evil of "reversed discrimination" and paternalism is to be avoided, a respect for other people demands that we can meet both other traditions and our own with a critical eye as well as a charitable ear.
In this account biomedical approaches to tuberculosis will be juxtaposed with local, traditional ways. I will go through some of Kleinman's key concepts to see how far they can take us in an attempt to try to understand what is going on in the field. I will argue that they can take us part of the way, but need to be supplemented. Studying clinical encounters and transactions is necessary, and can highlight some of the factors of importance to patients' choices about treatment. But a wider social context has to be considered in order to understand more of what it involves to be suffering from TB in a place like Bhojpur, and to grasp the dynamics involved in quests for therapy.
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